On any given day, some 1.7 million men and women are incarcerated in Federal and State prisons and local jails in the United States, and a recent study suggests that more than 80 percent of them are involved in substance use. In 1996 alone, taxpayers spent over $30 billion to incarcerate these individuals -- who are the parents of 2.4 million children. Put another way, one of every 144 American adults is behind bars for a crime in which substances are involved (The National Center on Addiction and Substance Abuse at Columbia University [CASA], 1998).
By a variety of measures, it is clear that substance use disorders disproportionately affect incarcerated Americans (Reuter, 1992; CASA, 1998; Federal Bureau of Prisons, 1997). Yet this population is significantly undertreated: Although prison substance use disorder programs annually treat more than 51,000 inmates, this figure represents less than 13 percent of the offender population identified as needing treatment. Studies also indicate that (with the exception of detoxification) most offenders have never received treatment in the community (Lipton et al., 1989; Peyton, 1994). Clearly, the majority of individuals in the criminal justice system in need of substance use disorder treatment are not receiving services -- either while they are incarcerated or after release to the community.
Providing substance use disorder treatment to offenders is good public policy. Recent research shows that punishment is unlikely to change criminal behavior, but substance use disorder treatment that also addresses criminal behavior can reduce recidivism (Andrews, 1994). Inmates with substance use disorders are the most likely to be re-incarcerated -- again and again -- and the length of their sentences continually increases. The more prior convictions an individual has, the more likely he has a substance use disorder. In State prisons, 41 percent of first offenders have used drugs, compared to 63 percent of inmates with two prior convictions and 81 percent of inmates with five or more prior convictions. Half of State parole and probation violators were under the influence of drugs, alcohol, or both when they committed their new offense. State prison inmates with five or more prior convictions are three times more likely than first-time offenders to be regular crack cocaine users (CASA, 1998). Offenders with substance use disorders not only crowd the nation's prisons, they are also responsible for a disproportionate amount of crime and for relatively violent crime. Compared to offenders who do not use drugs, drug-using "violent predators" commit many more robberies, burglaries, and other thefts (Chaiken, 1986).
However, offenders who have completed substance use disorder treatment during incarceration are still at great risk for relapse and recidivism when released. They need a variety of services to maintain sobriety during their transition from the institution to the community. This chapter provides an overview of the benefits of those transitional services. It also discusses obstacles to implementing such services and provides strategies for overcoming these obstacles. Finally, models for transitional services are described.
Some incarcerated offenders enter treatment for the same reasons as those "on the outside": They want to stop using substances and need help. Others, however, may have different motivations: boredom, the desire to improve their chances for parole, a wish to escape the violent culture of general population, or some combination of the above. Others may be mandated to treatment by the courts. Surprisingly, research shows that once an offender begins treatment, outcomes are not affected by the reasons for entering treatment (Leukefeld and Tims, 1988). A certain proportion of those who undergo treatment within the institution will succeed if supervised closely (Anglin and McGlothlin, 1984; Petersilia et al., 1992). Other key findings on the effectiveness of substance use disorder treatment within correctional institutions include the following:
Prerelease therapeutic communities have shown high rates of success among inmates studied (Wexler et al., 1988; Field, 1989).
Involvement in substance use disorder treatment is associated with decreased criminal recidivism. Improvements have been seen in rates of rearrest, conviction, reincarceration, and time to recidivate (Field, 1995a; Inciardi, 1996; Peters et al., 1993; Swartz et al., 1996; Wexler et al., 1990).
Involvement in substance use disorder treatment is associated with decreased substance use and relapse and other health-related outcomes (Inciardi, 1996; Martin et al., 1995; Wexler et al., 1990).
Duration of correctional substance use disorder treatment is associated with positive treatment outcomes. Research has shown that, up to a point, longer lengths of treatment are more effective than shorter lengths of treatment for substance-using offenders (Swartz et al., 1996; Wexler et al., 1992).
Involvement in substance use disorder treatment, such as prison-based therapeutic communities, is associated with successful parole outcomes (including reductions in parole revocations) (Field, 1989; Wexler et al., 1992).
Inmates involved in substance use disorder treatment had reduced rates of re-arrest and relapse when compared with inmates who did not participate (Federal Bureau of Prisons, 1998).
Service systems should provide offenders with appropriate treatment, since no treatment is likely to lead to continued drug use and crime. Treatment that stops when the offender is released, however, may not be enough. Release presents offenders with a difficult transition from the structured environment of the prison or jail: Despite the hardships endured "inside," they at least knew what to expect. Many offenders are released with no place to live, no job, and without family or social supports. They often lack the knowledge and skills to access available resources for adjustment to life on the outside, all factors that significantly increase the risk of relapse and recidivism (Leshner, 1997). The positive effects of substance use disorder treatment within correctional institutions may diminish once the offender moves out of the institutional environment unless followup care is provided in the community (Martin et al., 1995; Peters et al., 1992; Swartz et al., 1996).
The benefits of treatment during the transition from incarceration to the community are substantiated in several recent studies. In a study of drug offenders in Delaware, offenders who participated in 12 to 15 months of treatment in prison and another 6 months of treatment in the community were more than twice as likely to be drug-free 18 months after release as those who had only the prison treatment. Those offenders were also arrested much less in the year and a half following release (Inciardi, 1996). A similar study in California had comparable results (Wexler, 1996). Continuity of care from the institution to the community is associated with positive outcomes for prevention of relapse and criminal recidivism in other research as well (Swartz et al., 1996; Wexler et al., 1990).
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